The Road Traffic Acts require that diabetics (irrespective of treatment) who are either applicants or driving licence holders must notify the DVLA of their condition and of any problems or diabetes complications that develop that may affect the safety of driving. Failure to inform the DVLA is now a criminal offence. For medico-legal reasons, health-care professionals should document in the medical records that they have advised the patient to notify the DVLA. GPs may be contacted by a medical officer from the DVLA with a request for further information (usually a DIAB3 form), such as details about glycaemic control (particularly the risk of hypoglycaemia), visual problems and any limb problems.

The medical standards for licence entitlement (more stringent for Group 1 than Group 2 licences) include:

1. Adequate visual acuity with or without correction, equivalent of Snellen chart 6/12

2. Minimum visual field of at least 120° on the horizontal, with no significant defect in the binocular field

3. Adequate awareness of hypoglycaemia. In addition, if frequent episodes impair driving, then driving “must cease” until adequate control is regained

4. If limb disability is present, driving is possible in both static and progressive or relapsing disorders, but vehicle modification may be needed and the DVLA notified

5. Absence of significant symptoms, e.g. sudden disabling attacks of giddiness or fainting or impaired psychomotor or cognitive function.

Group I (ordinary) licence holders and applicants on insulin are granted a licence up to 3 years. On renewal they are required to make a self-declaration that may lead to medical enquiries. Those treated with diet and tablets or diet alone are permitted to hold a licence valid to 70 years of age, subject to the conditions and the need to report any change to insulin treatment. For Group 1 (ordinary) licence holders and applicants, a questionnaire (Diabetic 1) needs to be completed (downloadable: http://www.dvla.gov.uk/drivers/dmed1_files/pdf/diab1.pdf).

Since 1991, diabetics on insulin have been banned from applying for and renewing thereafter a Group 2 (bus, coach and large goods vehicle driver) licence. Diabetics on diet alone or diet and tablet treatment are permitted to hold a Group 2 licence, subject to the absence of any relevant disability and to not being on insulin. Also, drivers with insulin-treated diabetes should not drive emergency vehicles, due to “… the difficulties for an individual, regardless of whether they may appear to have exemplary glycaemic control, in adhering to the monitoring processes required when responding to an emergency situation” (DVLA 2006).

Insulin is a drug within the meaning of the Road Traffic Act 1988, and a driver “in control of a motor vehicle” with symptoms of hypoglycaemia runs the risk of being charged with driving under the influence of drugs. To avoid this and to correctly manage a hypoglycaemic episode:

• The vehicle must be stopped (with ignition switched off) and in a safe place

• The driver not seated behind the steering wheel

• The low blood glucose level should be corrected (with either a suitable source of sugar or glucagon)

and

• The journey should not be resumed until recovery is complete. This may take 15 or more minutes and the blood glucose level should be checked first.

INSURANCE

If an insurance company asks about diabetes, then the applicant must inform the company if he is diabetic. Failure to do so and also to notify the DVLA can invalidate cover in the event of a claim.

Since the Disability Discrimination Act (1995) came into effect at the end of 1996, insurers can refuse or charge more for cover only with evidence of an increased risk of making a claim. However, because most evidence available about diabetic drivers indicates that they pose no higher risk than nondiabetic drivers, many insurance companies no longer ask about diabetes when cover is applied for.

Some companies, who base their risk assessment on their experience of drivers with diabetes, may still refuse cover or impose special terms or charge an increased premium if their statistics “show” a higher risk. When this happens, it is worth challenging the insurer, especially if the applicant’s diabetes is stable and well controlled. It is always worth shopping around for quotes from a number of insurers, as premiums can vary considerably.

MEDICAL PROBLEMS THAT MAY AFFECT DRIVING

Patients and professionals need to be aware of the following that can affect driving:

• Visual problems arise usually from either retinopathy or cataract. Incorrectable deterioration of visual acuity, loss of peripheral visual field through widespread ablative retinal photocoagulation, may also result in loss of fitness to drive.

• Hypoglycaemia (discussed above).

• Neurological and/or vascular deficit may result in severe damage to the feet (leading to ulcers, or even amputation), and so also results in loss of fitness to drive.

• Arterial disease may result in cardiovascular and/or cerebrovascular disability, which affects fitness to drive.

• Alcohol lowers blood glucose levels, increasing the risk of hypoglycaemia in those on insulin or certain oral medication. A hypo may look like drunkenness; if the breath smells of alcohol this could heighten suspicion. Hyperglycaemia, even in the presence of ketones, will not affect a breathalyser machine.

IMMUNISATIONS

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Influenza and pneumonia are common, preventable infectious diseases associated with high mortality and morbidity in people with chronic diseases, such as diabetes. There are limited data on the morbidity and mortality of influenza and pneumococcal pneumonia specifically in diabetics. Safe and effective vaccines are available that can greatly reduce the risk of serious complications from these diseases. Unless contraindicated, the DoH recommends immunisation against influenza and pneumococcal pneumonia in all individuals with diabetes.

EMPLOYMENT

Diabetes UK has produced a useful booklet, Employment and diabetes.

FINDING A JOB

Diabetics on insulin are still not allowed to be in the following occupations:

• Driving either a heavy goods or public service or emergency vehicle

• Certain jobs in the Armed Forces, such as front-line troops and pilots

• Working offshore, such as on an oil rig or cruise ship

• Working at heights

• Being a jockey.

Since October 2004, blanket bans have been lifted for diabetics joining the police, fire and ambulance services, but applicants need to demonstrate that their diabetes is well controlled (with hypo-awareness), regularly monitored, and free of complications. The minimum levels of physical and mental fitness are still necessary for all applicants.

Any diabetic is entitled to be considered for any employment for which he is otherwise qualified. UK (via the Disability Discrimination Act) and European legislation offer protection against discrimination in employment against individuals with a medical condition such as diabetes. Due to a lack of up-to-date knowledge about diabetes, employers may fear that a diabetic poses a potential safety risk to the employer and/or the public. Most diabetics can manage their condition so that there is minimal risk of incapacitation from problems such as hypoglycaemia (ADA 2007). Employers need to consider whether the individual’s qualifications and medical circumstances (the condition, its treatment and any specific risks or problems) can be matched to the job specification. The Disability Rights Commission provides useful information for both employers and workers with long-term conditions such as diabetes.

Changing working hours

Working shifts can increase the risk of developing either metabolic syndrome or type 2 diabetes (Knutsson 2003). Altering working hours, such as changing shifts or working overtime, can disrupt eating and sleeping patterns in people with pre-existing diabetes, and may lead to a worsening of glycaemic control, particularly if the rotation pattern is rapid. Increased physical activity can affect blood glucose levels, and may require adjustments in calorific intake and treatment to maintain reasonable glycaemic control. Physically demanding work at unexpected times increases the risk of hypoglycaemia.

The following advice may be useful to diabetics working odd hours:

• Make sure meals or snacks are available

• Try to arrange meal breaks to be at set times

• Have a fast-acting carbohydrate snack readily available at all times in case of hypoglycaemia

• Monitor blood glucose levels more frequently

• Ensure that work colleagues are aware of diagnosis of diabetes, especially if working alone.

If on insulin, then it is sensible to use a newer prolonged-acting insulin (insulins glargine or detemir) as the basal insulin. These have the advantages of only being administered once daily and at the same time of day irrespective of the work pattern. Rapid-acting analogues (insulins lispro, aspart or glulisine) can then be administered to cover unpredictable and variable mealtimes. Where possible, patients should aim to time meals at 4 to 5 hour intervals, with snacks if required, and to keep to consistent quantities and types of food.

Adjustments to dosages, type and/or timing of insulin are usually necessary when working shifts, although administering insulin can usually be delayed 1 to 2 hours without significantly affecting diabetic control. This may be sufficient to cover an afternoon shift. If extra food is consumed later in the day, an appropriate increase in the later insulin dose may be needed. Major changes, such as moving to and from night shifts, require careful planning of food intake (more during the shift) and insulin administration, and patients may seek professional advice.